Selective Nonoperative Management in 1,856 Patients With Abdominal Gunshot Wounds: Should Routine Laparotomy Still Be the Standard of Care?

Abstract

ObjectiveTo evaluate the safety of a policy of selective nonoperative management (SNOM) in patients with abdominal gunshot wounds. Summary Background DataSelective nonoperative management is practiced extensively in stab wounds and blunt abdominal trauma, but routine laparotomy is still the standard of care in abdominal gunshot wounds. MethodsThe authors reviewed the medical records of 1,856 patients with abdominal gunshot wounds (1,405 anterior, 451 posterior) admitted during an 8-year period in a busy academic level 1 trauma center and managed by SNOM. According to this policy, patients who did not have peritonitis, were hemodynamically stable, and had a reliable clinical examination were observed. ResultsInitially, 792 (42%) patients (34% of patients with anterior and 68% with posterior abdominal gunshot wounds) were selected for nonoperative management. During observation 80 (4%) patients developed symptoms and required a delayed laparotomy, which revealed organ injuries requiring repair in 57. Five (0.3%) patients suffered complications potentially related to the delay in laparotomy, which were managed successfully. Seven hundred twelve (38%) patients were successfully managed without an operation. The rate of unnecessary laparotomy was 14% among operated patients (or 9% among all patients). If patients were managed by routine laparotomy, the unnecessary laparotomy rate would have been 47% (39% for anterior and 74% for posterior abdominal gunshot wounds). Compared with patients with unnecessary laparotomy, patients managed without surgery had significantly shorter hospital stays and lower hospital charges. By maintaining a policy of SNOM instead of routine laparotomy, a total of 3,560 hospital days and $9,555,752 in hospital charges were saved over the period of the study. ConclusionSelective nonoperative management is a safe method for managing patients with abdominal gunshot wounds in a level 1 trauma center with an in-house trauma team. It reduces significantly the rate of unnecessary laparotomy and hospital charges.During the past two decades selective nonoperative management (SNOM) has been used with increasing frequency for abdominal trauma. Many injuries previously managed exclusively by surgery are now being observed closely in the absence of peritonitis or hemodynamic instability. SNOM is considered the standard of care for blunt injuries and stab wounds and has decreased the rate of unnecessary laparotomy, shortened the length of hospital stay, and produced significant cost savings.1,2 However, abdominal gunshot wounds have been excluded from this advancement.

Tratamento não operatório das lesões renais por arma de fogo

“…Velmahos et al 18 conducted a study that included 1,856 patients with abdominal injury by firearms and showed that NOM was a safe method for trauma centers and significantly reduced the rate of unnecessary laparotomy and hospital expenses. Navsaria et al 17 obtained a success rate of 90.9% of non-operative treatment in a study with 33 patients suffering from renal injury by firearms.…”

“…Velmahos et al 18 conducted a study that included 1,856 patients with abdominal injury by firearms and showed that NOM was a safe method for trauma centers and significantly reduced the rate of unnecessary laparotomy and hospital expenses.…”

“…Exploratory laparotomy used to be recommended for all patients who presented with renal injury by penetrating trauma. However, nowadays the nonoperative treatment has been accepted with greater frequency in patients with lesions grade I, II or III by penetrating trauma, where there are no hollow viscera injuries or hemodynamic instability 3 .Velmahos et al 18 conducted a study that included 1,856 patients with abdominal injury by firearms and showed that NOM was a safe method for trauma centers and significantly reduced the rate of unnecessary laparotomy and hospital expenses. Navsaria et al 17 obtained a success rate of 90.9% of non-operative treatment in a study with 33 patients suffering from renal injury by firearms.…”

Experiences of Conflict Zone-Related Ballistic Renal Injury

“…In a large series of penetrating renal trauma, Wessels and his colleagues reported that the number of patients treated conservatively might increase [16]. Velmahos and his colleagues were able to follow up only 38 % of 1856 firearm injuries to kidney treated conservatively [17]. However, whether firearms had high or low kinetic energy were not specified in these studies.…”

General approach to penetrating abdomen traumas of Turkish General Surgeons: Survey of practice

“…[5][6][7][8][9][10] Son yirmi yılda özellikle gelişmiş görüntüleme teknikleri sayesinde SNOY yaklaşımının ateşli silaha bağlı karın yaralanmalarında da (ASY) etkili ve güvenilir olduğu gösterilmiştir. [11][12][13][14][15][16] The Eastern Association for the Surgery of Trauma Practice Management Guidelines Committee yayınladığı kılavuzda PKT'de hangi hastaların güvenle non-operatif olarak takip edilebileceğini belirtmiştir. Ancak non-operatif yönetim uygulanacak hastalarda gözden kaçan yaralanma veya tanıda gecikme riskinin dikkate alınması ve bu yüzden non-operatif yönetim uygulanacak hastaların seçimine özen gösterilmesi ve görüntüle-me teknikleri rehberliğinde yakın klinik takip önermektedir.…”